Panoramic on Epigenetics in Coronary Artery Disease and the Approach of Personalized Medicine.

Epigenetic modifications play a fundamental role in the progression of coronary artery disease (CAD). This panoramic review aims to provide an overview of the current understanding of the epigenetic mechanisms involved in CAD pathogenesis and highlights the potential implications for personalized medicine approaches. Epigenetics is the study of heritable changes that do not influence alterations in the DNA sequence of the genome. It has been shown that epigenetic processes, including DNA/histone methylation, acetylation, and phosphorylation, play an important role. Additionally, miRNAs, lncRNAs, and circRNAs are also involved in epigenetics, regulating gene expression patterns in response to various environmental factors and lifestyle choices. In the context of CAD, epigenetic alterations contribute to the dysregulation of genes involved in inflammation, oxidative stress, lipid metabolism, and vascular function. These epigenetic changes can occur during early developmental stages and persist throughout life, predisposing individuals to an increased risk of CAD. Furthermore, in recent years, the concept of personalized medicine has gained significant attention. Personalized medicine aims to tailor medical interventions based on an individual's unique genetic, epigenetic, environmental, and lifestyle factors. In the context of CAD, understanding the interplay between genetic variants and epigenetic modifications holds promise for the development of more precise diagnostic tools, risk stratification models, and targeted therapies. This review summarizes the current knowledge of epigenetic mechanisms in CAD and discusses the fundamental principles of personalized medicine.

Diagnostic and surgical management of HeartMate 3 outflow graft obstruction due to two different mechanisms.

Outflow graft obstruction is a potentially catastrophic complication of left ventricular assist devices that may occur secondary to different mechanisms. Two cases of Heartmate 3 outflow graft obstruction associated with two different pathophysiological mechanisms are presented. The first one was a 70-year-old man who developed outflow graft obstruction secondary to kinking. The second case was a 72-year-old man who presented with signs and symptoms of heart failure due to outflow graft extrinsic obstruction. Both cases were diagnosed with 3D-CT scan and successfully surgically treated.

Durability of the Liotta porcine bioprosthesis beyond two decades.

Porcine valves are generally known to have a limited durability. The case is reported of a 35-year-old male patient who underwent mitral valve replacement with a 28 mm Liotta porcine bioprosthesis. At reoperation 21 years later, the bioprosthesis was replaced (uneventfully) with a second porcine bioprosthesis. Pathological and X-radiographic examinations of the excised valve demonstrated focal calcification of the leaflets, confirming the long-term durability of the Liotta porcine bioprosthesis.

[Omentopexy associated with the use of Redon catheters in post-cardiac surgery mediastinitis with vascular prosthesis infection: immediate results in five patients]. / Omentopessi associata all'utilizzo dei cateteri di Redon nelle mediastiniti post-cardiochirurgiche con infezione di protesi vascolari: risultati immediati in cinque pazienti.

BACKGROUND: Post-cardiac surgery mediastinitis is a dangerous complication with an elevated mortality risk particularly when infection affects vascular prostheses. In this paper we report our experience with the use of extensive disinfection and washing of the mediastinum with iodopovidone, followed by omental transposition into the chest with the use of Redon catheters. METHODS: Between September 2001 and March 2007, 5 patients were treated with this technique (submitted to Bentall intervention in 2 cases, substitution of the ascending aorta, Bentall intervention with substitution of the aortic arch and substitution of the aortic arch in 1 case, respectively), due to a sternomediastinitis and correlated infection of the vascular prosthesis. Among them, 3 consisted of a redo surgery. RESULTS: One patient with unstable hemodynamic conditions died of multiorgan failure following a state of generalized sepsis; the remaining 4 patients had complete resolution of the clinical picture. None showed complications related to the procedure. The 4 survived patients were followed up at 1 month and underwent clinical and instrumental evaluation by chest computed tomography, which yielded negative results without signs of infection. CONCLUSIONS: Our limited experience definitely encourages us to use these combined techniques in the treatment of post-cardiac surgery mediastinitis in patients with vascular prostheses.

Clinical outcomes of mitral valve repair with the Colvin-Galloway Future Band: a single-center experience.

OBJECTIVES: In 2001, a semirigid band (Colvin-Galloway Future Band, Medtronic, Inc., Minneapolis, Minnesota, USA) for mitral valve repair came onto the market. We report our experience of the correction of all types of mitral regurgitation using this device. METHODS: From August 2003 to December 2006, 140 patients (71% men, mean age 64 +/- 11 years) underwent valvuloplasty with this device for all types of mitral regurgitation: 94 (67%) degenerative, 34 (24%) postischemic, 11 (8%) dilative cardiomyopathy, and one (1%) postendocarditic. The patients underwent clinical and echocardiographic evaluation preoperatively, postoperatively before discharge, and after a median follow-up of 7 months (25th-75th percentile, 4-24 months). RESULTS: Total mortality was 6.4% (nine out of 140 patients): four patients (2.8%) died within 30 days (early death) and five died subsequently (the cause was cardiac in one case). Predischarge echocardiographic examination revealed a reduction in mitral regurgitation of at least 2 degrees in 99.2% of patients and the absence of systolic anterior movement. At the last follow-up, we recorded an improvement in New York Heart Association functional class (2.4 +/- 0.9 vs. 1.1 +/- 0.4, P < 0.0001), a significant reduction in the degree of mitral regurgitation (3.5 +/- 0.9 vs. 0.9 +/- 0.5, P < 0.0001), an increase in ejection fraction (54 +/- 11 vs. 55 +/- 9, P = 0.09), and a significant reduction in end-diastolic diameter (59 +/- 6 vs. 55 +/- 6, P < 0.0001). Two patients were reoperated on for mitral valve replacement, and no postoperative thromboembolic events occurred. CONCLUSION: Our experience shows that the Colvin-Galloway Future Band yields good results in mitral valvuloplasty for all types of mitral regurgitation. We are encouraged to continue using this device.

Long-term outcome after pulmonary endarterectomy.

RATIONALE: There are few follow-up studies on long-term cardiopulmonary function after pulmonary endarterectomy (PEA), the operation of choice for chronic thromboembolic pulmonary hypertension (CTEPH). OBJECTIVES: To prospectively evaluate long-term outcome of patients with CTEPH treated with PEA. METHODS: Between 1994 and 2006, 157 patients (mean age 55 yr) were treated with PEA at Pavia University Hospital. The patients were evaluated before PEA and at 3 months (n = 132), 1 year (n = 110), 2 years (n = 86), 3 years (n = 69), and 4 years (n = 49) afterward by NYHA class, right heart hemodynamic, spirometry, carbon monoxide transfer factor (Tl(CO)), arterial blood gas, and treadmill incremental exercise test. MEASUREMENTS AND MAIN RESULTS: Cumulative survival was 84%. Within 3 months, 18 patients died in-hospital and 2 had lung transplantation; during long-term follow-up, 6 died, 1 had lung transplantation, and 3 had a second PEA (2.5 events per 100 person-years). NYHA class III-IV was the most important predictor of late death, lung transplant, or PEA redo (hazard ratio, 3.94). Extraordinary improvement in NYHA class, hemodynamic, and Pa(O(2)) were achieved in the first 3 months (P < 0.001) and persisted during follow-up; exercise tolerance progressively increased over time (P < 0.001). At 4 years, although 74% of the patients were in NYHA class I and none was in class IV, 24% had pulmonary vascular resistance greater than 500 dyne.s/cm(5) or Pa(O(2)) less than 60 mm Hg; they were significantly older and were more frequently in NYHA class III-IV 3 months after surgery than the others. CONCLUSIONS: After PEA, long-term survival and cardiopulmonary function recovery is excellent in most patients.

[Bentall operation after previous repair of tetralogy of Fallot]. / Intervento di Bentall in paziente con pregresso intervento di correzione di tetralogia di Fallot.

Pathologies that involve the ascending aorta are described in case reports of patients after complete repair of tetralogy of Fallot. Here, we present a case report. Preoperative tests showed an aortic ratio of > 1.5. The patient was operated on replacement of the ascending aorta according to the Bentall technique. At present, the guidelines for replacement of the ascending aorta recommend an aortic ratio of > 1.5 and in case of Marfan syndrome of > 1.3. In these patient subsets, cystic medial necrosis and an increased risk of aortic dissection have been described. Therefore, as for Marfan syndrome, why an aortic ratio of >1.3 should not be considered a proper surgical indication also for these patients?

[Surgical treatment of chronic thromboembolic pulmonary hypertension with pulmonary endarterectomy]. / Terapia chirurgica dell'ipertensione polmonare cronica tromboembolica mediante endoarteriectomia polmonare.

Acute pulmonary embolism is the third most common cardiovascular disease in Italy with approximately 65 000 new cases a year. Appropriate medical therapy does not necessarily prevent evolution of acute pulmonary embolism into chronic thromboembolic pulmonary hypertension (CTEPH), which occurs in 0.1-4.0% of cases. In our country, there are approximately up to 2600 new CTEPH patients a year. CTEPH is a progressive and potentially lethal disease. Medical therapy is palliative and only surgery can modify its natural history. Pulmonary endarterectomy (PEA) is the treatment of choice and lung transplantation should be considered only when PEA is contraindicated. Currently, nearly 4000 PEAs have been performed worldwide. Approximately ten centers are able to carry out this intervention with excellent and permanent results. Solid experience and close multidisciplinary collaboration allow appropriate patient selection, rigorous surgical technique, and adequate postoperative management. All these aspects represent the key to the success in the treatment of CTEPH. After PEA, quality and expected length of life are similar to the age-matched general population and the only therapy required is oral anticoagulation.